The false security of low injury rates
May 8, 2009
Achieving zero harm is today’s new paradigm. Most companies agree that getting to zero harm is the only acceptable safety goal â€” but many continue to function within models and cultures incompatible with zero-harm performance.
This article begins a series exploring four critical ideas essential to achieving the zero-harm goal. We begin by looking at why zero-harm organizations focus their efforts on exposure instead of injuries. (Editor’s note: follow-up articles will appear in ISHN’s June, September and October issues.)
New goal, new thinking
The zero-harm goal is not an extension of injury-reduction goals of the past (e.g. “We have achieved 1.0, now let’s aim for 0.5”). Too many organizations with low injury rates continue to have fatalities, recordkeeping violations, and so on.
Zero-harm performance is about creating environments where injuries are not acceptable and where we do everything possible to prevent them. We are not just targeting a lower number â€” we are developing a new way of thinking about safety performance.
The traditional focus on injuries as the measure of performance and the trigger for change is incompatible with the zero-harm goal. Injury statistics are too imprecise and too reactive to support the goal of doing everything possible to prevent an injury. But there is another reason why zero-harm organizations move their attention further upstream from safety outcomes: an injury focus can lull us into a false sense of security.
The injury focus fallacy
The injury focus promotes the fallacy that we can predict with certainty what decisions and actions will (or will not) result in an injury. Because of this thinking, many organizations leave individual employees, supervisors, managers, and senior leaders to “risk assess” their own decisions and actions.
None of us can truly determine whether or not a decision we’ve made will lead to an injury. The person who decides to stand on the pump motor to reach a valve, the supervisor who allows work to proceed even when the ground is iced over, the manager who puts off the repair due to budget constraints, the senior leader who decides to miss the company safety summit â€” all are making an assessment of the consequences of their actions and betting that no injury will result.
Here is the problem: each person is at the same time allowing exposure to rise above acceptable levels. As a result, the policies, procedures, best practices and rules that establish acceptable levels of exposure are ignored or overridden. Every time this happens, the outcome is no better than a roll of the dice.
In almost any incident investigation, you will find somewhere in the chain of events a slippage that increased the exposure from known standards. Ask any injured employee (or their supervisor) two simple questions: “Before you proceeded, did you think you or someone else was going to be injured?” and “Did you recognize the exposure was rising?” The answer to the first question will almost always be no; the answer to the second will almost always be yes.
Consider a real-life example: Three employees go out to change the medium in a filter. The filter is 15 feet above ground level and not equipped with a work platform. The workers get an impact wrench and a bucket lift to get to the top of the filter. The studs holding the lid on the filter are so corroded, however, that the impact is not strong enough to remove them. The workers get down and ask the supervisor for permission to get a hammer wrench and hammer from the tool room. The supervisor grants the request and tells them to be careful. The workers again use the lift to go back to the top of the filter.
Given the need for operating room, one worker remains below. One worker fastens the wrench on the first nut while the other one swings the sledge hammer, contacting the striking surface of the wrench. The wrench slips from his grip, hits the edge of the bucket, and strikes the third worker standing below, breaking several bones in his hand.
When asked about the incident later, the employees agreed that the exposure went up when they made the switch. When asked why they decided to proceed regardless, the answer was not production pressure, but that they did not think the exposure had elevated enough to cause an injury.
The truth is, there is exposure around us at all times. Simply choosing to get out of bed in the morning increases your exposure. The goal for organizations, however, is not a “pie-in-the-sky” world of zero exposure. It is simply managing exposure to the standards the organization has already set with its rules, procedures, policies, best practices, and training. It is getting everyone to pause and rethink the decisions they are about to make every time they have to deviate from the original plan.
If everyone was to ask the simple question, “Have I brought the exposure back down to specified levels?”, injury rates would plummet. Organizations that take this one step further by aiming to lower exposure from existing standards are on a concrete path to zero.
Until we move the focus from injury prevention to exposure management, we will continue to be surprised by seemingly out-of-the-blue events. Asking people to act despite their belief that an injury will not occur â€” to halt the work, to OK the repair, to stop the crew, to miss the meeting at corporate so as to be visible for the safety summit â€” will not be easy. Making this change requires that we also rethink our culture and climate, a shift we will discuss in the next installment.